The human health effects of unconventional oil and gas development (UOGD): A scoping review of epidemiologic studies.

OBJECTIVE: Unconventional oil and gas development (UOGD, sometimes termed "fracking" or "hydraulic fracturing") is an industrial process to extract methane gas and/or oil deposits. Many chemicals used in UOGD have known adverse human health effects. Canada is a major producer of UOGD-derived gas with wells frequently located in and around rural and Indigenous communities. Our objective was to conduct a scoping review to identify the extent of research evidence assessing UOGD exposure-related health impacts, with an additional focus on Canadian studies. METHODS: We included English- or French-language peer-reviewed epidemiologic studies (January 2000-December 2022) which measured exposure to UOGD chemicals directly or by proxy, and where health outcomes were plausibly caused by UOGD-related chemical exposure. Results synthesis was descriptive with results ordered by outcome and hierarchy of methodological approach. SYNTHESIS: We identified 52 studies from nine jurisdictions. Only two were set in Canada. A majority (n = 27) used retrospective cohort and case-control designs. Almost half (n = 24) focused on birth outcomes, with a majority (n = 22) reporting one or more significant adverse associations of UOGD exposure with: low birthweight; small for gestational age; preterm birth; and one or more birth defects. Other studies identified adverse impacts including asthma (n = 7), respiratory (n = 13), cardiovascular (n = 6), childhood acute lymphocytic leukemia (n = 2), and all-cause mortality (n = 4). CONCLUSION: There is a growing body of research, across different jurisdictions, reporting associations of UOGD with adverse health outcomes. Despite the rapid growth of UOGD, which is often located in remote, rural, and Indigenous communities, Canadian research on its effects on human health is remarkably sparse. There is a pressing need for additional evidence.

RéSUMé: OBJECTIF: L'exploitation pétrolière et gazière non conventionnelle (EPGNC, parfois appelée « fracturation ¼ ou « fracturation hydraulique ¼) est un processus industriel d'extraction du méthane et/ou de gisements de pétrole. De nombreux produits chimiques utilisés dans l'EPGNC ont des effets indésirables connus sur la santé humaine. Le Canada est un grand producteur de gaz dérivé de l'EPGNC, dont les puits sont souvent situés à l'intérieur et autour de communautés rurales et autochtones. Nous avons mené une étude de champ pour déterminer l'étendue des données de recherche évaluant les effets sur la santé de l'exposition à l'EPGNC, en nous concentrant plus particulièrement sur les études canadiennes. MéTHODE: Nous avons inclus des études épidémiologiques en anglais ou en français évaluées par les pairs (janvier 2000 à décembre 2022) qui mesuraient l'exposition directe ou indirecte aux produits chimiques de l'EPGNC et dans lesquelles les résultats cliniques étaient plausiblement causés par l'exposition aux produits chimiques liés à l'EPGNC. La synthèse des résultats est descriptive, et les résultats sont ordonnés selon les résultats cliniques et l'approche méthodologique. SYNTHèSE: Nous avons identifié 52 études menées dans neuf juridictions. Deux seulement étaient canadiennes. La majorité (n = 27) faisaient appel à des cohortes rétrospectives ou étaient des études cas-témoins. Près de la moitié (n = 24) portaient sur les issues de la grossesse, et la majorité (n = 22) déclaraient une ou plusieurs associations indésirables significatives entre l'exposition à l'EPGNC et : l'insuffisance de poids à la naissance; la petite taille du bébé pour son âge gestationnel; la naissance avant terme; et une ou plusieurs anomalies congénitales. D'autres études faisaient état d'effets indésirables, dont l'asthme (n = 7), les troubles respiratoires (n = 13), les troubles cardiovasculaires (n = 6), la leucémie aiguë lymphoblastique infantile (n = 2) et la mortalité toutes causes confondues (n = 4). CONCLUSION: Il existe dans différents pays un corpus croissant d'études qui font état d'associations entre l'EPGNC et des résultats sanitaires indésirables. Malgré la croissance rapide de l'EPGNC, souvent présente dans des communautés éloignées, rurales et autochtones, la recherche canadienne sur ses effets sur la santé humaine est remarquablement clairsemée. Il y a un besoin urgent de recueillir d'autres données probantes à ce sujet.

Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis.

BACKGROUND: Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS: We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS: Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION: Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.

Advance Care Planning in the Nursing Home Setting: A Practice Improvement Evaluation.

This study evaluated a practice improvement initiative conducted over a 6 month period in 15 Canadian nursing homes. Goals of the initiative included: (1) use the Plan-Do-Study-Act (PDSA) model to improve advance care planning (ACP) within the sample of nursing homes; (2) investigate whether improved ACP practice resulted in a change in residents' hospital use and ACP preferences for home-based care; (3) engage participating facilities in regular data collection to inform the initiative and provide a basis for reflection about ACP practice and; (4) foster a team-based participatory care culture. The initiative entailed two cycles of learning sessions followed by implementation of ACP practice improvement projects in the facilities using a PDSA approach by participating clinicians (e.g., physicians, social workers, nurses). Clinicians reported significantly increased confidence in many dimensions of ACP activities. Rates of hospital use and resident preference for home-based care did not change significantly. The initiative established routine data collection of outcomes to inform practice change, and successfully engaged physicians and non-physician clinicians to work together to improve ACP practices. Results suggest recurrent PDSA cycles that engage a 'critical mass' of clinicians may be warranted to reinforce the standardization of ACP in practice.

Associations between polypharmacy and treatment intensity for hypertension and diabetes: a cross-sectional study of nursing home patients in British Columbia, Canada.

OBJECTIVES: Describe nursing home polypharmacy prevalence in the context of prescribing for diabetes and hypertension and determine possible associations between lower surrogate markers for treated hypertension and diabetes (overtreatment) and polypharmacy. DESIGN: Cross-sectional study. SETTING: 6 nursing homes in British Columbia, Canada. PARTICIPANTS: 214 patients residing in one of the selected facilities during data collection period. PRIMARY AND SECONDARY OUTCOME MEASURES: Polypharmacy was defined as ≥9 regular medications. Overtreatment of diabetes was defined as being prescribed at least one hypoglycaemic medication and a glycosylated haemoglobin (HbA1c) ≤7.5%. Overtreatment of hypertension required being prescribed at least one hypertension medication and having a systolic blood pressure ≤128 mm Hg. Polypharmacy prescribing, independent of overtreatment, was calculated by subtracting condition-specific medications from total medications prescribed. RESULTS: Data gathering was completed for 214 patients, 104 (48%) of whom were prescribed ≥9 medications. All patients were very frail. Patients with polypharmacy were more likely to have a diagnosis of hypertension (p=0.04) or congestive heart failure (p=0.003) and less likely to have a diagnosis of dementia (p=0.03). Patients with overtreated hypertension were more likely to also experience polypharmacy (Relative Risk (RR))1.77 (1.07 to 2.96), p=0.027). Patients with overtreated diabetes were prescribed more non-diabetic medications than those with a higher HbA1c (11.0±3.7vs 7.2±3.1, p=0.01). CONCLUSION: Overtreated diabetes and hypertension appear to be prevalent in nursing home patients, and the presence of polypharmacy is associated with more aggressive treatment of these risk factors. The present study was limited by its small sample size and cross-sectional design. Further study of interventions designed to reduce overtreatment of hypertension and diabetes is needed to fully understand the potential links between polypharmacy and potential of harms of condition-specific overtreatment.

Variation in site of death among nursing home residents in British Columbia, Canada.

OBJECTIVE: To assess the proportion of in-hospital versus in-nursing home deaths among a population of decedent nursing home residents in British Columbia, Canada, and to identify facility and individual characteristics associated with in-hospital death. METHODS: We examined nursing home (ownership/organization, size) and individual (age, level of care, sex, previous hospitalization within 30 days) characteristics of all decedent residents of British Columbia's freestanding publicly funded nursing homes. Secondary administrative data from the Ministry of Health, supplemented with facility data were analyzed. The study population included those aged 65 years and older who died between April 1, 1996 and August 1, 1999 (n = 14,413). Mixed models were used to estimate unadjusted and adjusted odds ratios (AOR; 95% confidence intervals [CI]) for factors associated with in-hospital death. RESULTS: Almost one quarter (24.6%) of deaths occurred in hospital. In-hospital death was more frequent in nonprofit (NP) single-site facilities compared to NP facilities owned and/or operated by a health authority (AOR = 1.37, 95% CI: 1.15, 1.64). Smaller nursing home size (AOR = 1.25, 95% CI: 1.05, 1.50) and male gender (AOR = 1.17, 95% CI: 1.07, 1.27) were also associated with a greater odds of in-hospital death. Progressively lower odds ratios of in-hospital death were observed for each category of increasing age and declining function, respectively. CONCLUSIONS: While individual characteristics play a significant role in explaining variation in site of death, residence in a NP single-site and smaller-sized facility was also associated with a greater frequency of in-hospital death.